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General NPI Number Information
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NPI Number | 1558676627
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Entity Type | Organization
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Legal Business Name | SOUTHERN CALIFORNIA INJURY TREATMENT CENTER, LLC
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Dates
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Enumeration Date | 08/13/2010
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Last Update Date | 08/13/2010
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Provider Practice Location Address
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Address Line | 14365 PIPELINE AVE
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City | CHINO
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State | CA
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Zip | 91710-5642
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Country | US
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Telephone | 909-364-8111
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Fax | 909-591-0538
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Provider Business Mailing Address
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Address Line | 14365 PIPELINE AVE
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City | CHINO
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State | CA
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Zip | 91710-5642
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Country | US
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Telephone | 909-364-8111
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Fax | 909-591-0538
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Authorized Official
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Title or Position | ORTHOPEDIC SURGEON
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Name | DR. CLYDE O. HARRIS III
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Credential | M.D.
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Telephone | 909-364-8111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | G041089
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License Number State | CA
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